User:Charleneguo/sandbox

Planned Article Topic: I would like to expand upon specific sections of the "Juul" article on Wikipedia

- Add onto the "Usage" section regarding the prevalence of Juul use among adolescents specifically; reasons why it is so popular and data showing this

- Further expand upon the potential health effects of the Juul in the "health concerns" section; add about how nicotine affects the adolescent brain

Usage
Prevalence among Adolescents

The creators of the Juul, James Monsees and Adam Bowen, have stated that the mission of the Juul is to improve adult smokers' lives by eliminating cigarettes. While its intended use is to provide adults with an alternative to cigarettes, the Juul has gained traction among teenagers.

Usage of the Juul is very popular among teenagers. The verb "Juuling" is used by teenagers to describe their use of Juul. An online survey conducted in November 2017 found that 7% of American teenagers aged 15–17 and 12% of American young adults aged 18–24 reported having ever used a Juul. In an annual study, the National Drug Trends of 2018 revealed an increasing use of e-cigarettes, including the Juul. Cigarette smoking rates among 12th graders continued to decline as it has been for two decades. On the other hand, the increase in vaping rates from 2017 to 2018 was the largest gap recorded since the study began in 1975. Researchers hypothesize this may be due to the number of educational programs implemented to warn youth of the risks of cigarette smoking, while there is still a lack of programs regarding vaping devices. The percentage of 12th grade students who reported vaping nicotine almost doubled, from 11% in 2017 to 21% in 2018. Among 10th graders, the percentage doubled from 8% to 16%. Furthermore, a Truth Initiative study found that of 15 to 17-year-old teenagers who use Juul, 56% used the device more than three times a month. Over 25% of teenagers reported using the Juul more than ten times a month. These findings suggest that teenagers are not just experimenting with Juuls, but rather using them on a regular basis.

Many reasons have been proposed for Juul's popularity among teenagers. Among these are adolescents' misperceptions regarding nicotine content, its ease of concealment, sleek high-tech design, and Juul pod flavors.

A 2015 Stanford University study analyzing adolescents’ perceptions of risks and benefits of conventional cigarettes and e-cigarettes found that many of the participants believed that e-cigarettes did not contain nicotine, only water vapor. Additionally, the 2017 Truth Initiative survey found 63% of teens and young adults do not understand that the Juul they use always contains nicotine. A lack of educational programs and public health campaigns regarding the use of e-cigarettes and Juuls reflect how teenagers may perceive these devices as many of the risks are still unknown. Former PAX Labs CEO Goldman said to Fortune in 2016 that "Juul should not be used by those under the legal age, nor should any nicotine products, as stated by the U.S. Surgeon General." In 2018 Matt Myers, president of Campaign for Tobacco-Free Kids, said the design "misleads about risk" of addiction.

Juul's resemblance to a flash drive makes it easy to conceal, and its low vapor output and subtle scent, which can be passed off as perfume, mean that it can be used discreetly, even in class. Similarly, the device's small size allows it to be concealed in clothing or elsewhere; a high school in Newton, Massachusetts discovered a Juul disguised as a sharpie, for instance. Juul's sleek and high-tech design, which is often compared to that of the iPhone, is also often cited as a reason for its popularity with young people.

Finally, Juul's sweet flavors, especially the fruit and crème brûlée ones, are especially attractive to teenagers, according to journalists, academics,  and the U.S. Food and Drug Administration. Unlike the cigarette smoke smell, Juuls can emit a fruity scent when vaped. In a 2016 study analyzed by the CDC and FDA, 31% of middle and high school students who use e-cigarettes claimed they used them due to the availability of flavors. In response, Juul renamed some flavors—"cool cucumber" to "cucumber" and "crème brûlée" to "creme"—saying that it "heard the criticism" and "responded by simplifying the names and losing the descriptors." They also changed the name "classic menthol" to just "menthol," again, to simplify their product names.

Many of Juul's early market campaigns have been youth-orientated, with their prominent use of social media and young models pictured using Juuls. In response to the FDA crackdown on Juul, the company announced they would be using real customers who were using the product to switch from smoking instead of models. As of November 2018, Juul has shut down their social media accounts.

A 2018 Truth Initiative survey found that 74% of Juul users ages 12–17 got their device from a brick and mortar store, 52% got theirs from a friend or family member, and only 6% got theirs online (respondents could select multiple answers). For context, Juul estimates that 90% of its sales are in brick and mortar stores.

Health concerns
Much is still unknown about the full range of potential effects that the Juul may cause. A comprehensive report concludes that there is substantial evidence that nicotine intake from e-cigarettes and cigarettes can be comparable. Besides nicotine, e-cigarettes contain much less toxic substances and carcinogens compared to conventional cigarettes. In youth, there is substantial evidence that using e-cigarettes increases the chance of them ever smoking conventional cigarettes. Researchers are still looking into if Juuling can cause cancer or other respiratory diseases, as well as its short and long term effects on the heart and lungs.

Nicotine Content

Although e-cigarettes such as the Juul may help adults quit smoking cigarettes, studies have shown that there is substantial evidence that the use of e-cigarettes among youth exposes them to the risk of developing a nicotine dependency and increases the risk of them transitioning to smoking conventional cigarettes. One Juul pod contains the same amount of nicotine as one to two packs of cigarettes. The nicotine content of Juuls is higher than other e-cigarette brands with its volume of e-liquid containing 5% nicotine, almost double the amount that other brands contain. Juul pods also contain a greater amount of benzoic acid, 44.8 mg/mL, as compared to other brands, which contain around 0.2 to 2 mg/mL. Constant exposure to benzoic acid can lead to coughing, sore throat, and abdominal pain.

Juuls are unique from other e-cigarettes in that they use "nicotine salts" rather than "freebase nicotine" in order to reproduce the effects that conventional cigarettes offer smokers. Nicotine salts are also less acidic than freebase nicotine, making it easier to inhale. Additionally, nicotine salts are more readily absorbed into the bloodstream at a rate similar to conventional cigarettes. Due to its lack of irritation and easiness to inhale, users may be unaware of how much nicotine they are actually intaking.

Ari Atkins, Pax Labs' R&D engineer, said "We don't think a lot about addiction here because we’re not trying to design a cessation product at all." He added, "anything about health is not on our mind." In April 2018, FDA Commissioner Dr. Scott Gottlieb stated that the nicotine in Juul is sufficient to result in addiction. Gottlieb further stated, "In some cases, our kids are trying these products and liking them without even knowing they contain nicotine. And that's a problem, because as we know the nicotine in these products can rewire an adolescent's brain, leading to years of addiction."

Effect of Nicotine on the Adolescent Brain

Nicotinic acetylcholine receptors (nAChRs) are ligand-gated ion channels that can respond to nicotine. nAChR subtypes are located throughout the central and peripheral nervous systems. The most abundant nAChR subtype, α4β2, has the highest affinity for nicotine. These receptors are mostly desensitized in the brains of smokers. Preclinical studies using rodents have shown that nicotine produces age-specific behavioral responses that differ between adolescents and adults. For instance, acute nicotine exposure enhanced locomotor activity in adolescents while it decreased locomotor activity in adults. Exposure to nicotine in adolescents also affects serotonin levels.

Concerns about the effect of nicotine delivered by Juul on the developing adolescent brain led to a lawsuit against the company. The suit, filed in US District Court in New York in June 2018, alleged that Juul contains more nicotine than necessary to satisfy an adult smoker, and that use of Juul by the 15-year-old son of the plaintiff made him "heavily addicted to nicotine" causing him to be "anxious, highly irritable and prone to angry outbursts".

In late 2018, news reports noted increasing rates of Juul addiction in teenagers, which negatively impacts brain development and relationships. Juul's high nicotine content has attracted concern because of nicotine's addictive properties and also because nicotine can cause impaired lung and brain development, especially of the prefrontal cortex, which affects judgement and impulse control. Particular concern has been expressed about the lack of vaping cessation treatments for adolescents, and the FDA has scheduled a public hearing on youth vaping cessation.